Top of Cardiac Disease Table - Important hx Flashcards
What should you aways do if someone comes in from chest pain
IV access
What life threatening conditions must you exclude
Acute ACS Aortic dissection Tension pneumothorax PE Oesophageal rupture
Beware
Female / elderly / DM NOT presenting with typical signs
What are key investigations
Hx ECG - reference to previous Troponin 6 hours post worst pain CXR Bloods D-dimer only if Well's = low probability
What is important in Hx
SOCRATES - Character of pain - Sudden or with exertion Any SOB Any diaphoresis / nausea
Why CXR
Rule of Ddx of ACS
What bloods
FBC U+E LFT Cholesterol TFT
If <12 hours + abnormal ECG
Emergency
If 12-72 hours
Same day assessment
If >72 hour
Full assessment
ECG
Cardiac enzyme
Then decide about referral
Other Ddx
Pericarditis Pneumonia Pleural effusion Empyema GORD Oesophageal spasm MSK Shingles Intra-abdominal - Cholecystitis - Peptic ulcer - Pancreatitis Anxiety = tingling lips / finger Sickle cell crisis
What is MSK pain
Worse on pain / movement / pressing
May have Hx trauma or cough
What can it be
Muscular
RIb fracture
Bony mets
Costrochondriits- viral
What can cause palpitations
Arrhythmia
Stress
Increased awareness
What are red flags + admit to AMIA
Syncope
Broad complex tachy
2 or 3 heart block
Sustained SVT after vagal
What are 1st line tests (beware may be normal if episodic)
Examine CVS inc pulse and BP
12 lead ECG in ALL
Bloods
What bloods
FBC
U+E - K?
TFT - hyper?
If there is normal ECG, no PMH and minimal Sx what do you do
Safety ned
If concerning features / abnormal ECG
Cardiology referral
What do you do for episodic
Holter - 24 ECG
Keep a diary of symptoms at time of monitoring
What do you want to know in Hx of dyspnoea
Known resp / cardiac disease Anaphylaxis Onset At rest or on exertion - How much exertion - Baseline Any orthopnoea - pillow Any PND Other Sx PMH / RF RF VTE
What other Sx
Chest pain Palpitations Oedema Infective - cough / sputum / fever / coryza RF for VTE
What does dyspnoea at rest suggest
Hypoxia or increased work of breathing (if no hypoxia) FB Tumour Bronchitis Anaphylaxis Asthma
What do you assess for with examination
Wheeze Stridor Chest - clear - crep Signs of overload Other - Pneumothorax - Pleural effusion
Wheeze
Anaphylaxis
Asthma
COPD
HF
When do you worry and what does it suggest
Stridor
- FB
- Tumour
- Acute epiglottis
- Anaphylaxis
When would chest be clear with breathlessness
PE Hyperventilation Metabolic acidosis Anaemia Drugs Shock PJP DKA CNS disease
What investigations
Baseline obs - O2, HR, RR, temp PEFR ABG if sats <92% or concern about acidosis ECG CXR Baseline bloods - FBC, U+E, glucose - Consider drug
Syncope
See geriatrics
What is syncope
Transient LOC due to global cerebral hypoperfusion
Rapid onset, short duration and spontaneous recovery
What are mechanism of syncope
Reflex Orthostatic Cerebrovascular Cardiac Seizure
What is most common
Reflex neuromediated
What can cause
Vasovagal Situational - Cough - Micturition Carotid sinus sensitivity
What is vasovagal
HR doesn’t increase in response to stimuli so MAP decreases = syncope
Triggered by emotion / pain / stress
Pre-drome - sweat / nausea /
If not recurrent = no further investigation
What causes orthostatic
Primary autonomic failure
- Parkinson’s / MSA
- Lewy body
Secondary
- DM
- Amyloid
- Addison
Drugs
- Diuretic
- Vasodilator
- Alcohol
Volume depletion
- Haemorrhage
- Diarrhoea
- Sepsis
- Dehydration
What can precipitate
Prolonged rest
After meals
Venous pooling during exercise or pregnancy
What is the classic description
Sustained reduction in BP >20 / 10 <3 minutes of standing
May have pre syncope Sx
What are pre-syncope
Palpitation
Light headed
Blurred vision
Weak
Cerebrovascular
Stroke
TIA
Subclavian steal
What is typical of cardiac syncope
Normal after
No memory of event
No prior Sx
Can be recurrent
What are cardiac causes
Bradycardia - AV conduction - Sinus node Tachy - SVT or ventricular Long QT Brugada Drug Device malfunction Structural - Valve - MI - HCM - Myxoma PE - affects R side but will eventually decrease CO Pericarditis / dissection / tamponade
What are red flags
Exertional Supine Recent MI Heart disease Palpitations Abnormal ECG FH sudden death
How do you investigate
H+E inc CVS and neuro Postural BP ECG Bloods Urine dip / CXR - rule out infection Drug review CT head
What bloods
FBC, U+E, LFT CRP BG Ca / Mg Short SYnacthen for Addison's
When CT head
If anti-coagulation or >65 to rule out subdural
What are further test
Carotid sinus massage
Tilt table test
- To see if related to change in position or HR
24 hour holter
When is carotid sinus +V
If pause >3s on ECG after massage
or fall in SBP >50
How do you treat vasovagal with no recurrence
Avoid trigger
Reassure
Education
How do you treat orthostatic
TED
Review meds
Ensure no dehydration
Treat DM / neuropathy / Addison’s
How do you treat cardiac
Pacemaker
AVR
DVLA if unexplained syncope
NO driving
If no cause found then lift in 6 months
If due to seizure
6 months if 1st seizure
1 year seizure free
If vasovagal attributed to a cause
No restriction
MI DVLA
After 4 weeks